Spontaneous Spinal Epidural Hematoma Presenting as Conus Medullaris Syndrome in a Patient with Protein C and S Deficiency on Warfarin Managed with Surgical Decompression.

Abstract

Spontaneous spinal epidural hematoma (SSEH) is a rare neurological emergency characterized by the accumulation of blood in the epidural space causing acute cord compression. We report a 42-year-old male with Protein C and S deficiency on long-term warfarin for deep venous thrombosis, who developed sudden low back pain and neurological deficit suggestive of conus medullaris syndrome. MRI revealed intradural hematoma at D12-L1 with cord edema. After urgent anticoagulation reversal and emergency decompression, an epidural hematoma was confirmed. Postoperatively, anticoagulation was resumed with heparin, later shifted to warfarin. With rehabilitation, neurological status improved from Frankel C to Frankel E, and follow-up MRI at one year showed complete hematoma resolution. SSEH is rarely reported in warfarinized patients with therapeutic INR and has not been linked to Protein C/S deficiency. Sudden spinal pain with rapid neurological deficit warrants immediate MRI, prompt anticoagulation reversal, and urgent decompression for optimal recovery. The online version contains supplementary material available at 10.1007/s43465-025-01686-x.